Hospitals striving to both improve the quality of care they deliver and better control costs should take a look at a new kind of intensive care unit specifically for patients with chronic, advanced or terminal illness. Called acute palliative care units, they benefit patients and their families by focusing not only on their medical needs, but on their psychological, emotional and spiritual needs, as well. They also relieve pressure on the typical ICU and provide significant cost savings in a number of ways.

Proponents acknowledge that not all hospitals have the need or wherewithal to create separate units specifically for palliative care. However, the APCU model holds valuable lessons for any organization setting up a palliative care program, a number that has grown by leaps and bounds over the last decade or so. In 2000, 600 hospitals had established palliative care teams; by 2012, that number had surged to 1,600.

Montefiore Medical Center created its 15-bed APCU six years into its palliative care program. "The reason we started this is because we had seen that there were many patients in critical care units and medical-surgical units who could benefit from a combination of palliative care and general medical care," explains Marlene McHugh, R.N., assistant professor of clinical nursing at Columbia University School of Nursing and associate director of palliative care at Montefiore in the Bronx. McHugh co-authored a study published in June in the American Journal of Hospice & Palliative Medicine that describes the Montefiore unit. Patients are directly managed by palliative care specialists trained in chronic disease management, as well as family and end-of-life counseling. That has an obvious impact on quality of care, but also on costs. "This combination of advanced disease management and personal counseling can assist patients and families in the transition from aggressive treatment to more palliative care," according to researchers. "In fact, recent studies indicate that palliative care counseling can shorten ICU stays, reduce costs and enhance overall quality of care."

The study cited some dramatic cost savings, including:

  • The median hospital charge for room and board in the APCU was less than half the cost of an ICU.
  • Ventilator costs were nearly five times as high in the ICU ($10,399) vs. the APCU ($2,123) and a third lower than in the med-surg unit ($2,870).
  • Pharmacy costs were nearly five times higher in the ICU ($1,645) than in the APCU ($156) and nearly twice as high in the med-surg unit ($342).

McHugh says the key is a "consistent team" — a physician who is board-certified in palliative care medicine, as well as physician assistants, nurses and social workers — that keeps patients and families updated, understands their wishes, makes sure tests are not unnecessarily repeated and that all the care delivered is appropriate.

There's a growing consensus in health care that all clinicians dealing with critically ill patients should have some training in palliative care, and McHugh agrees. As "palliative care moves upstream," she says, "we should think about every provider having the ability to manage patients from a medical standpoint and from a palliative care standpoint." That applies even to hospitals and health systems that might never set up an APCU.

"If you're a physician running an ICU in a community hospital, you're not going to be able to have an APCU, but, hopefully, you're going to have some skills to work with that patient and family regarding what their goals of care are, what the patient's support is and to support the family," she says.

One of the interesting things about the Montefiore APCU is that it is an "open unit." That means that a patient's longtime physician, who may not be affiliated with the medical center, is allowed to admit the patient into it. The physician continues to oversee the patient's care, aided by the unit's physician assistants, nurses and social workers. The physician knows the patient's history, and the patient is comforted by keeping his own physician, and benefits from the palliative care expertise of the unit's staff.

Content by Health Forum, Sponsored by: VHA.